Reviewing Acne looking initially at symptoms and different types - with some self help tips

Acne

Acne Vulgaris (referred to as acne for short) is a disorder of skin glands that produce a natural oil (Sebum). The face, neck, shoulders, upper chest, and back are most frequently affected. It affects more than one in two young adults at some stage, usually beginning at puberty and clearing completely before the mid-twenties. In many adolescents, acne clears within two years. The reason acne is worse during puberty is due to an increase in sex hormones called androgens, especially testosterone (even women have small amounts of testosterone) and these excess hormones make oil glands overactive and enlarged thus producing too much oil (sebum). Too much sebum causes the pores or hair follicles to become blocked with skin cells and a buildup of bacteria in these blockages. Testosterone levels increase during puberty, peaking in the late teens then leveling off hence acne tends to reduce after puberty. Diet has little influence on acne. Despite what is commonly believed, sugary foods and fatty foods, such as chocolate and chips, have not been proven to contribute to acne.

Symptoms

Definitions and terms used for symptoms of acne

Medically, clinicians use the term lesions to describe the bumps on the skin experienced during acne.

Lesion is an overall term that can describe the different bumps caused by acne and include:

• Papules: raised bumps
• Pustules: raised bump often known as a pimple and filled with yellowish fluid known as pus; pus contains sebum (oil) that gets trapped in the pores mixed with dead skin cells and bacteria
• Comedones: raised bumps that can form blackheads and whiteheads
• Nodules: this is a bump under the skin which may not be visually obvious to someone else but can be painful.
• Cysts: look like a boil and can be filled with pus.

Comedonal acne is the name of acne which is characterised by inflamed skin blemishes (i.e.) papules which are like red bumps. These papules form due to hair follicles and pores becoming blocked with skin cells and oil which leads to white-heads and black-heads.

Role of bacteria

Bacteria on the skin surface intensify the problem by producing chemicals that inflame and irritate the skin. The anaerobic bacterium Cutibacterium acnes (C. Acnes) plays an important role in maintenance of healthy skin but acne creates an ideal environment for its excessive growth. An environment which includes inflammation, lesions with excess sebum and dead skin cells allows C. Acnes to multiply thus exacerbating the problem and contributing to inflammation. Prior to 2016, Cutibacterium Acnes was named Propionibacterium acnes (P. acnes) and was renamed C Acnes to better reflect the biochemical and genomic makeup of this bacterium.

Whiteheads and blackheads

Whiteheads are tiny little clogged pores just below the surface of the skin which are not inflamed. Blackheads are like whiteheads except they are open to the air which oxidises with the sebum and keratin in the skin and gives them a brown/black colour. Do not attempt to squeeze these as this causes them to get irritated and inflamed and cause a little red bump on the skin (a papule). Papules develop mainly on the T-zone (ie) forehead, nose, and chin. Healthy bacteria on the skin (e.g., C acnes) can form in these papules causing them to fill with pus and develop a defined white or yellow head on the surface called a pustule.

More pronounced lumps

Cysts and nodules are large painful lumps underneath the skin which can take weeks to heal. The only difference between the two is that nodules are hard and don’t have an obvious white/yellow head whereas cysts are fluid filled with a defined white or yellow head. Do not squeeze these as it will cause scarring and possibly spread to surrounding pores.  

Medication induced acne

Some medication can cause acne so doctors and phamacists must take this into account if patients prescribed these medication present with acne. They should only be reviewed and changed if acne is severe and only if the benefits of changing them outweigh the risks (eg. Acne is causing severe psychological issues for the patient) as many of the medication implicated with acne are for serious ong term health condtions so should not be changed without a suitable alternative which may not always be avaialble. Examples of medication that can cause acne type symptoms include anti-epileptics such as phenytoin, phenobarbital and carbamazepine, mood stabilisers such as lithium, anti-tuberculous medication such as rifampicin, isoniazid and ethionamide and the immunosuppressant ciclosporin which is mainly used to prevent transplant rejection and inflammatory autoimmune conditions such as rheumatoid arthritis and psoriasis.

Acne is not linked to rosacea

Rosacea is an inflammatory skin disease causing facial flushing, redness, papules, pustules and in some cases permanent dilation of small blood vessels (known as telangiectasia). In rosacea the cheeks, chin, forehead, and nose are usually worse affected with the rest of the face mainly unaffected. Rosacea can be temporary in some cases but is often recurrent or persistent. There are four subtypes of rosacea, these are: erythematotelangiectic rosacea, papulopustular rosacea, phymatous rosacea and ocular rosacea

Rosacea is sometimes referred to as acne rosacea; however, this can cause confusion as rosacea is unrelated to acne vulgaris. Rosacea is mostly diagnosed in people aged 40 – 59 years and is rare in under people under 30. Some of the treatment options like azelaic acid (Skinoren^®) and oral antibiotics (e.g., minocycline, doxycycline) are similar for acne and rosacea. I discussed rosacea previously in Irish Pharmacist.

Self help

• Most cases of mild acne will be helped by washing affected areas no more than twice daily; washing more often can irritate acne more.
• Use a mild soap or cleanser and use lukewarm water as very hot or cold water can worsen acne
• Avoid vigorous scrubbing while washing acne-affected skin. Avoid the use of abrasive soaps, cleansing granules, astringents, or exfoliating washes. A soft washcloth and fingers should be used instead.
• Do not try to “scrub off” blackheads. Scrubbing or picking acne will exacerbate acne.
• Women should avoid overuse of makeup and cosmetics and avoid greasy cosmetic products. Remove makeup completely at night.
• If dry skin is a problem due to the medication used for acne, aim to use a fragrance-free, water-based emollient. Avoid ointments or oil rich creams as they clog pores.
• Cream preparations tend to be less irritating to acne than gels.
• Avoid food stuffs that patients feel worsen the problem though there are no specific food groups that are thought to exacerbate acne. A healthy diet is the best recommendation.
• While sunlight help our skin produce vitamin D, it is a myth that sunlight improves acne.